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Insurance coverage for equip

My insurance(Aetna) would not cover my blood pressure cuff for autonomic dysreflexia. They said it was "experimental usage" and there was no CMS code for AD and blood pressure cuffs. A year later, I am still fighting the appeal.

Has anyone ever had their insurance cover their blood pressure cuff? Any suggestions how to get the thing covered? It is less than $75 but I refuse to pay on principal. If I need to, I want to get CMS to add AD to coverage codes. I use nitropaste and the cuff helps me know when to wipe the paste off.

Anyone have suggestions? SCI Nurse, will the VA cover them and under what codes?

KLD wil have to answer that about VA but the code could be for management of hypertension (or hypotension). They are more ikey to it since you have Nitropaste prescribed. AD is probaby too complicated.

Not only does the VA cover them for patients at risk for AD, we REQUIRE the patient at risk to get one and learn how to use it. We provide them to patients at risk through their Prosthetics & Sensory Aids coverage (from VA supplies), so there is no "code" for this.

Have you asked your SCI physician to write a justification? There is nothing "experimental" about taking a blood pressure, and if the insurance does not have AD coded in their manuals, so clerk is just jerking you around. Ask for a review of your request by a physiatrist (at the expense of the insurance company) not just by any physician or nurse.

It would also be worth it to try it as CWO suggests and have your physician justify it for management of "labile hypertension" which should show up in their coding book.

I use an automated cuff as it is the only way I can take my blood pressure independently. Here is what the insurance says:

Blood Pressure Monitors and Stethoscopes:

Notes: Home blood pressure monitors (sphygmomanometers, blood pressure cuffs) and stethoscopes do not meet Aetna’s definition of covered durable medical equipment in that they may be of use in the absence of illness and injury. Following Medicare rules, Aetna covers blood pressure monitors and stethoscopes only for members receiving hemodialysis or peritoneal dialysis in the home.

Aetna considers automated oscillometer blood pressure (BP) monitors (e.g., Dinamap and Omron) for home use experimental and investigational because they have not been demonstrated to provide better health outcomes than conventional BP monitors (see background).

See also CPB 025 - Automated Ambulatory Blood Pressure Monitoring

We have even provided PVA clinical guidelines for the practitioner as well as a letter of appeal.

Aetna considers automated ambulatory blood pressure monitoring medically necessary according to the selection criteria listed below, which are based on guidelines developed by the American College of Physicians/American Society of Internal Medicine.

Note: Ambulatory blood pressure monitoring for more than 3 days is not considered medically necessary.

Member must meet any of the following criteria:

Office or "white coat" hypertension: The physician suspects "white coat" hypertension or a transient rise of blood pressure that occurs in the office setting. The member has blood pressure readings repeatedly elevated to a mild degree in the office setting (systolic readings of 140 to 150 mm Hg and/or diastolic readings of 90 to 99 mm Hg) and no definitive diagnosis of hypertension has been established despite all of the following:

The physician has performed at least three blood pressure measurements at least 1 week apart in the office; and
Blood pressure measurements by non-physicians (e.g., nurse, technician) have been done and mild hypertensive readings have been obtained; and
Member has repeated blood pressure measurements at home over at least one month, and the diagnosis of hypertension remains in question.

Resistant hypertension: Ambulatory blood pressure monitoring is considered medically necessary prior to instituting an invasive investigation (e.g., renin vein assays, angiogram for renal artery stenosis) for secondary causes of hypertension for members with hypertension that is refractory to medications.
Evaluation of hypotensive symptoms: Ambulatory blood pressure monitoring is considered medically necessary for members with hypotensive symptoms and/or syncopal events that are thought to be related to antihypertensive medications.
Nocturnal angina: Ambulatory blood pressure monitoring is considered medically necessary to investigate blood pressure changes in members with nocturnal angina.
Episodic hypertension: Ambulatory blood pressure monitoring is considered medically necessary for members whose symptomatology (paroxysms of excessive sweating, palpitations, apprehension) suggests episodic hypertension secondary to an adrenal tumor (e.g., pheochromocytoma), and office blood pressure measurements are repeatedly normal.
Evaluation of syncope: Ambulatory blood pressure monitoring is considered medically necessary when used in conjunction with a 24-hour Holter monitor (see CPB 019 - Holter Monitors ) to determine whether symptoms of syncope or near syncope are the direct result of an arrhythmia.

Aetna considers the use of ambulatory blood pressure monitoring experimental and investigational in any of the following situations because the medical literature does not support its use in these conditions:

For routine monitoring to establish the clinical diagnosis of hypertension or to evaluate the member's blood pressure responses to treatment; or
For members with an irregular cardiac rhythm (e.g., atrial fibrillation). Blood pressure reading are inconsistent and unreliable when an irregular cardiac rhythm is present due to variances in pulse volume; or
For monitoring normal or borderline hypertensive blood pressure readings in the medical setting of members with documented evidence of end-organ damage (e.g., nephropathy, electrocardiographical changes, left ventricular hypertrophy, angina, myocardial infarction, cerebrovascular accident, transient ischemic attack) or cardiovascular risk factors (e.g., diabetes mellitus, smoking, hypercholesterolemia); or
Use of an ambulatory blood pressure monitor for more than 3 days is not considered medically necessary; or
Use for diagnosing malignant (accelerated phase) hypertension. Under accepted guidelines, malignant hypertension requires urgent hospital admission for appropriate investigation and treatment; or
Blood pressure monitoring of pregnant women who do not meet any of the criteria listed above; or
Blood pressure monitoring for heart failure.

Background
Automated ambulatory blood pressure monitoring is an outpatient procedure using fully automated devices to measure ambulatory blood pressure at frequent intervals during the day and night in an effort to determine the variability of a patient's blood pressure due to environmental stresses and to aid in definitively establishing a diagnosis of hypertension before committing the patient to life-long antihypertensive therapy.

Since treatment is rarely urgent in the absence of severe hypertension, the physician's diagnosis of hypertension should be substantiated first by repeated office readings by well-trained non-physicians. If the diagnosis is not established by non-physicians taking blood pressure measurement, a month trial of patient self-measurement of blood pressures in the home at varying times during the day should be tried.

Patients with borderline hypertensive measurements in the office setting should have basic cardiovascular tests done. Those who have evidence of target-organ damage or other cardiovascular risk factors should receive non-pharmacologic and/or pharmacologic treatments without further investigation. Studies have unequivocally demonstrated that these patients have a significant risk of developing cardiovascular disease and will benefit from antihypertensive therapy. Patients with no evidence of target-organ damage and no risk factors should be classified by a trial of self-measured blood pressures; drug treatment should be considered for patients with consistently elevated readings in this setting.

The accuracy, patient acceptability and mechanical reliability of ambulatory blood pressure devices remain controversial. Studies have not shown that continuous ambulatory monitoring is superior to random, frequent patient self-measurement with a calibrated blood pressure cuff. In addition, data management and analysis have not been standardized and are arbitrarily determined. Studies that showed the relationship between blood pressure and cardiovascular disease risk and the clinical trials that documented the efficacy of antihypertensive drug therapy were based on casual office measurements. Furthermore, the American College of Physicians recommends that a physician-measured diastolic blood pressure reading of 90 to 99 mm Hg be utilized to establish a firm diagnosis of hypertension.

Automated ambulatory blood pressure monitoring is not medically necessary for the diagnosis and management of hypertension in most patients; however, its use is indicated in rare subgroups of hypertensive patients with specific clinical problems, which are identified by the patient selection criteria indicated.

In a systematic review, Goyal, et al. (2005) stated that "ambulatory blood pressure monitoring has established its use in the definition of white coat hypertension and monitoring of treatment of essential hypertension. Any role for ambulatory blood pressure monitoring in heart failure is not well defined….Prospective controlled studies on the impact of treatments on circadian blood pressure profile in congestive heart failure patients are needed".

It would seem to me that AD causes episodic hypertension, which is on the list, although clearly not due to the cause they list.
They claim the monitor is not supported for diagnosis of malignant hypertension. I guess they mean that you need to go to the ER if you experience hypertension. Would they rather pay for repeated ER trips because you suspect that you may have AD, or for a BP monitor that costs a small fraction of one ER visit? What idiots - it's definitely in their direct interest to supply you with the monitor. As you say, AD should be added to thir coverage codes.
KLD's approach may work.
- Richard